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Neel DV, Baselga-Garriga C, Benson M, Keegan M, Chase M, D'Agostino D, Drake K, Hagar JL, Hasenoehrl MG, Kulesa-Kelley J, Leite A, Mohapatra S, Portaro SM, Pothier LM, Rosenthal J, Sherman AV, Yu H, McCaffrey A, Ho D, Luppino S, Bedlack R, Heitzman D, Ajroud-Driss S, Katz J, Felice K, Whitaker C, Ladha S, Alameda G, Locatelli E, Qureshi IA, Hotchkin MT, Hayden MR, Cudkowicz ME, Babu S, Berry JD, Paganoni S. Multicenter expanded access program for access to investigational products for amyotrophic lateral sclerosis. Muscle Nerve 2024; 70:232-239. [PMID: 38842106 DOI: 10.1002/mus.28169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 05/03/2024] [Accepted: 05/12/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION/AIMS Expanded access (EA) is a Food and Drug Administration-regulated pathway to provide access to investigational products (IPs) to individuals with serious diseases who are ineligible for clinical trials. The aim of this report is to share the design and operations of a multicenter, multidrug EA program for amyotrophic lateral sclerosis (ALS) across nine US centers. METHODS A central coordination center was established to design and conduct the program. Templated documents and processes were developed to streamline study design, regulatory submissions, and clinical operations across protocols. The program included three protocols and provided access to IPs that were being tested in respective regimens of the HEALEY ALS Platform Trial (verdiperstat, CNM-Au8, and pridopidine). Clinical and safety data were collected in all EA protocols (EAPs). The program cohorts comprised participants who were not eligible for the platform trial, including participants at advanced stages of disease progression and with long disease duration. RESULTS A total of 85 participants were screened across the 3 EAPs from July 2021 to September 2022. The screen failure rate was 3.5%. Enrollment for the regimens of the platform trial was completed as planned and results informed the duration of the corresponding EAP. The verdiperstat EAP was concluded in December 2022. Mean duration of participation in the verdiperstat EAP was 5.8 ± 4.1 months. The CNM-Au8 and pridopidine EAPs are ongoing. DISCUSSION Multicenter EAPs conducted in parallel to randomized clinical trials for ALS can successfully enroll participants who do not qualify for clinical trials.
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Affiliation(s)
- Dylan V Neel
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Clara Baselga-Garriga
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Molly Benson
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mackenzie Keegan
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marianne Chase
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Derek D'Agostino
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kristin Drake
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer Linn Hagar
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Meredith Gibbons Hasenoehrl
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer Kulesa-Kelley
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alex Leite
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Silpa Mohapatra
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Susanna Marie Portaro
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lindsay M Pothier
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jesse Rosenthal
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander V Sherman
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hong Yu
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexandra McCaffrey
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Doreen Ho
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Luppino
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard Bedlack
- Department of Neurology, Duke University, Durham, North Carolina, USA
| | | | | | - Jonathan Katz
- California Pacific Medical Center Research Institute and Forbes Norris MDA/ALS Research and Treatment Center, San Francisco, California, USA
| | - Kevin Felice
- Department of Neuromuscular Medicine, Hospital for Special Care, New Britain, Connecticut, USA
| | - Charles Whitaker
- Department of Neuromuscular Medicine, Hospital for Special Care, New Britain, Connecticut, USA
| | - Shafeeq Ladha
- Gregory W. Fulton ALS and Neuromuscular Center, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Eduardo Locatelli
- Center for Collaborative Research, Nova Southeastern University and Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, Florida, USA
| | | | | | - Michael R Hayden
- Naarden, Prilenia Therapeutics, The Netherlands
- Center for Molecular Medicine and Therapeutics, British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Merit E Cudkowicz
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Suma Babu
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James D Berry
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sabrina Paganoni
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Dhaenens BAE, Heimann G, Bakker A, Nievo M, Ferner RE, Evans DG, Wolkenstein P, Leubner J, Potratz C, Carton C, Iloeje U, Kirk G, Blakeley JO, Plotkin S, Fisher MJ, Kim A, Driever PH, Azizi AA, Widemann BC, Gross A, Parke T, Legius E, Oostenbrink R. Platform trial design for neurofibromatosis type 1, NF2-related schwannomatosis and non-NF2-related schwannomatosis: A potential model for rare diseases. Neurooncol Pract 2024; 11:395-403. [PMID: 39006526 PMCID: PMC11241353 DOI: 10.1093/nop/npae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024] Open
Abstract
Background Neurofibromatosis type 1, NF2-related schwannomatosis and non-NF2-related schwannomatosis (grouped under the abbreviation "NF") are rare hereditary tumor predisposition syndromes. Due to the low prevalence, variability in the range, and severity of manifestations, as well as limited treatment options, these conditions require innovative trial designs to accelerate the development of new treatments. Methods Within European Patient-Centric Clinical Trial Platforms (EU-PEARL), we designed 2 platform-basket trials in NF. The trials were designed by a team of multidisciplinary NF experts and trial methodology experts. Results The trial will consist of an observational and a treatment period. The observational period will serve as a longitudinal natural history study. The platform trial design and randomization to a sequence of available interventions allow for the addition of interventions during the trial. If a drug does not meet the predetermined efficacy endpoint or reveals unacceptable toxicities, participants may stop treatment on that arm and re-enter the observational period, where they can be re-randomized to a different treatment arm if eligible. Intervention-specific eligibility criteria and endpoints are listed in intervention-specific-appendices, allowing the flexibility and adaptability needed for highly variable and rare conditions like NF. Conclusions These innovative platform-basket trials for NF may serve as a model for other rare diseases, as they will enhance the chance of identifying beneficial treatments through optimal learning from a small number of patients. The goal of these trials is to identify beneficial treatments for NF more rapidly and at a lower cost than traditional, single-agent clinical trials.
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Affiliation(s)
- Britt A E Dhaenens
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- ENCORE Expertise Centre for Neurodevelopmental Disorders, Erasmus MC, Rotterdam, The Netherlands
| | - Günter Heimann
- Biostatistics & Pharmacometrics, Novartis Pharma AG, Basel, Switzerland
| | | | - Marco Nievo
- Children's Tumor Foundation, New York, New York, USA
| | - Rosalie E Ferner
- Neurofibromatosis Service, Department of Neurology, Guy's and St. Thomas' NHS Foundation Trust London, Great Maze Pond, London, UK
| | - D Gareth Evans
- Centre for Genomic Medicine, Division of Evolution, Infection and Genomic Sciences, University of Manchester, St Mary's Hospital, Manchester, UK
| | | | - Jonas Leubner
- Department of Pediatric Neurology, Charité Universitätsmedizin Berlin-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Cornelia Potratz
- Department of Pediatric Neurology, Charité Universitätsmedizin Berlin-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | | | - Uchenna Iloeje
- Medical Affairs, SpringWorks Therapeutics, Stamford, Connecticut, USA
| | | | - Jaishri O Blakeley
- Department of Neurology, Neuro-Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Scott Plotkin
- Cancer Center and Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael J Fisher
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - AeRang Kim
- Division of Oncology, Children's National Hospital, Washington DC, District of Columbia, USA
| | - Pablo Hernáiz Driever
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Amedeo A Azizi
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Wien, Austria
| | - Brigitte C Widemann
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Andrea Gross
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | | | - Eric Legius
- Department of Human Genetics, KU Leuven, Leuven, Belgium
- Department of Clinical Genetics, UZ Leuven, Leuven, Belgium
- Full Member of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS), Nijmegen, The Netherlands (E.L., R.O.)
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- ENCORE Expertise Centre for Neurodevelopmental Disorders, Erasmus MC, Rotterdam, The Netherlands
- Full Member of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS), Nijmegen, The Netherlands
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Kawano-Dourado L, Kulkarni T, Ryerson CJ, Rivera-Ortega P, Baldi BG, Chaudhuri N, Funke-Chambour M, Hoffmann-Vold AM, Johannson KA, Khor YH, Montesi SB, Piccari L, Prosch H, Molina-Molina M, Sellares Torres J, Bauer-Ventura I, Rajan S, Jacob J, Richards D, Spencer LG, Wendelberger B, Jensen T, Quintana M, Kreuter M, Gordon AC, Martinez FJ, Kaminski N, Cornelius V, Lewis R, Adams W, Jenkins G. Adaptive multi-interventional trial platform to improve patient care for fibrotic interstitial lung diseases. Thorax 2024; 79:788-795. [PMID: 38448221 PMCID: PMC11287572 DOI: 10.1136/thorax-2023-221148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/06/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Fibrotic interstitial lung diseases (fILDs) are a heterogeneous group of lung diseases associated with significant morbidity and mortality. Despite a large increase in the number of clinical trials in the last 10 years, current regulatory-approved management approaches are limited to two therapies that prevent the progression of fibrosis. The drug development pipeline is long and there is an urgent need to accelerate this process. This manuscript introduces the concept and design of an innovative research approach to drug development in fILD: a global Randomised Embedded Multifactorial Adaptive Platform in fILD (REMAP-ILD). METHODS Description of the REMAP-ILD concept and design: the specific terminology, design characteristics (multifactorial, adaptive features, statistical approach), target population, interventions, outcomes, mission and values, and organisational structure. RESULTS The target population will be adult patients with fILD, and the primary outcome will be a disease progression model incorporating forced vital capacity and mortality over 12 months. Responsive adaptive randomisation, prespecified thresholds for success and futility will be used to assess the effectiveness and safety of interventions. REMAP-ILD embraces the core values of diversity, equity, and inclusion for patients and researchers, and prioritises an open-science approach to data sharing and dissemination of results. CONCLUSION By using an innovative and efficient adaptive multi-interventional trial platform design, we aim to accelerate and improve care for patients with fILD. Through worldwide collaboration, novel analytical methodology and pragmatic trial delivery, REMAP-ILD aims to overcome major limitations associated with conventional randomised controlled trial approaches to rapidly improve the care of people living with fILD.
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Affiliation(s)
- Leticia Kawano-Dourado
- Hcor Research Institute, Hcor Hospital, Sao Paulo, Brazil
- Pulmonary Division, Heart Institute (InCor), University of Sao Paulo, Sao Paulo, Brazil
- MAGIC Evidence Ecosystem Foundation, Oslo, Norway
| | - Tejaswini Kulkarni
- The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Christopher J Ryerson
- Department of Medicine and Centre of Heart Lung Innovations, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pilar Rivera-Ortega
- Interstitial Lung Disease Unit, Respiratory Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Bruno Guedes Baldi
- Pulmonary Division, Heart Institute (InCor), University of Sao Paulo, Sao Paulo, Brazil
| | - Nazia Chaudhuri
- Department of Health and Life Sciences, School of Medicine, University of Ulster, Londonderry, UK
| | - Manuela Funke-Chambour
- Department for Pulmonology, Allergology and clinical Immunology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Anna-Maria Hoffmann-Vold
- Department of Rheumatology, Oslo University Hospital, Oslo, Norway
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Kerri A Johannson
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yet Hong Khor
- Respiratory Research@Alfred, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Sydney B Montesi
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lucilla Piccari
- Department of Pulmonology, Hospital del Mar, Barcelona, Spain
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - María Molina-Molina
- Servei de Pneumologia, Grup de Recerca Pneumològic, Institut d'Investigacions Biomèdiques de Bellvitge (IDIBELL), Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Jacobo Sellares Torres
- Grup de Treball de Malalties Pulmonars Intersticials. Pneumology Service, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Iazsmin Bauer-Ventura
- Rheumatology Division, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Sujeet Rajan
- Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Joseph Jacob
- Centre for Medical Imaging and Computing, University College London, London, UK
- Department of Respiratory Medicine, University College London, London, UK
| | - Duncan Richards
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lisa G Spencer
- Liverpool Interstitial Lung Disease Service, Aintree Hospital, Liverpool University Hospitals NHS Foundation Trust Library and Knowledge Service, Liverpool, UK
| | | | | | | | - Michael Kreuter
- Mainz Center for Pulmonary Medicine, Department of Pulmology, Mainz University Medical Center and Department of Pulmonary, Critical Care & Sleep Medicine, Marienhaus Clinic Mainz, Mainz, Germany
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York City, New York, USA
| | - Naftali Kaminski
- Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Roger Lewis
- Berry Consultants, Los Angeles, California, USA
| | - Wendy Adams
- Action for Pulmonary Fibrosis Foundation, London, UK
| | - Gisli Jenkins
- Margaret Turner Warwick Centre for Fibrosing Lung Disease, National Heart and Lung Institute, Imperial College London, London, UK
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Weemering DN, Beelen A, Kliest T, van Leeuwen LAG, van den Berg LH, van Eijk RPA. Trial Participation in Neurodegenerative Diseases: Barriers and Facilitators: A Systematic Review and Meta-Analysis. Neurology 2024; 103:e209503. [PMID: 38830181 PMCID: PMC11244742 DOI: 10.1212/wnl.0000000000209503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/29/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Clinical trials in neurodegenerative diseases often encounter selective enrollment and under-representation of certain patient populations. This delays drug development and substantially limits the generalizability of clinical trial results. To inform recruitment and retention strategies, and to better understand the generalizability of clinical trial populations, we investigated which factors drive participation. METHODS We reviewed the literature systematically to identify barriers to and facilitators of trial participation in 4 major neurodegenerative disease areas: Alzheimer disease, Parkinson disease, amyotrophic lateral sclerosis, and Huntington disease. Inclusion criteria included original research articles published in a peer-reviewed journal and evaluating barriers to and/or facilitators of participation in a clinical trial with a drug therapy (either symptomatic or disease-modifying). The Critical Appraisal Skills Program checklist for qualitative studies was used to assess and ensure the quality of the studies. Qualitative thematic analyses were employed to identify key enablers of trial participation. Subsequently, we pooled quantitative data of each enabler using meta-analytical models. RESULTS Overall, we identified 36 studies, enrolling a cumulative sample size of 5,269 patients, caregivers, and health care professionals. In total, the thematic analysis resulted in 31 unique enablers of trial participation; the key factors were patient-related (own health benefit and altruism), study-related (treatment and study burden), and health care professional-related (information availability and patient-physician relationship). When meta-analyzed across studies, responders reported that the reason to participate was mainly driven by (1) the relationship with clinical staff (70% of the respondents; 95% CI 53%-83%), (2) the availability of study information (67%, 95% CI 38%-87%), and (3) the use or absence of a placebo or sham-control arm (53% 95% CI 32%-72%). There was, however, significant heterogeneity between studies (all p < 0.001). DISCUSSION We have provided a comprehensive list of reasons why patients participate in clinical trials for neurodegenerative diseases. These results may help to increase participation rates, better inform patients, and facilitate patient-centric approaches, thereby potentially reducing selection mechanisms and improving generalizability of trial results.
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Affiliation(s)
- Daphne N Weemering
- From the Department of Neurology (D.N.W., T.K., L.A.G.v.L., L.H.v.d.B., R.P.A.v.E.), Department of Rehabilitation, Physical Therapy Science & Sports (A.B.), and Center of Excellence for Rehabilitation Medicine (A.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; De Hoogstraat Rehabilitation (A.B.), Utrecht; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Anita Beelen
- From the Department of Neurology (D.N.W., T.K., L.A.G.v.L., L.H.v.d.B., R.P.A.v.E.), Department of Rehabilitation, Physical Therapy Science & Sports (A.B.), and Center of Excellence for Rehabilitation Medicine (A.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; De Hoogstraat Rehabilitation (A.B.), Utrecht; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Tessa Kliest
- From the Department of Neurology (D.N.W., T.K., L.A.G.v.L., L.H.v.d.B., R.P.A.v.E.), Department of Rehabilitation, Physical Therapy Science & Sports (A.B.), and Center of Excellence for Rehabilitation Medicine (A.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; De Hoogstraat Rehabilitation (A.B.), Utrecht; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Lucie A G van Leeuwen
- From the Department of Neurology (D.N.W., T.K., L.A.G.v.L., L.H.v.d.B., R.P.A.v.E.), Department of Rehabilitation, Physical Therapy Science & Sports (A.B.), and Center of Excellence for Rehabilitation Medicine (A.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; De Hoogstraat Rehabilitation (A.B.), Utrecht; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Leonard H van den Berg
- From the Department of Neurology (D.N.W., T.K., L.A.G.v.L., L.H.v.d.B., R.P.A.v.E.), Department of Rehabilitation, Physical Therapy Science & Sports (A.B.), and Center of Excellence for Rehabilitation Medicine (A.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; De Hoogstraat Rehabilitation (A.B.), Utrecht; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Ruben P A van Eijk
- From the Department of Neurology (D.N.W., T.K., L.A.G.v.L., L.H.v.d.B., R.P.A.v.E.), Department of Rehabilitation, Physical Therapy Science & Sports (A.B.), and Center of Excellence for Rehabilitation Medicine (A.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; De Hoogstraat Rehabilitation (A.B.), Utrecht; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
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Saygin D, Werth V, Paik JJ, Park JK, Needham M, Lundberg IE, Christopher-Stine L. Current myositis clinical trials and tribulations. Ann Rheum Dis 2024; 83:826-829. [PMID: 38216318 DOI: 10.1136/ard-2023-224652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 12/30/2023] [Indexed: 01/14/2024]
Abstract
With improved understanding of disease pathogenesis and availability of outcome measures, there has been a remarkable increase in the number of therapeutic clinical trials in idiopathic inflammatory myopathies (myositis) over the last three years reaching as many as five trials per site. These trials share similar design and inclusion/exclusion criteria resulting in a competitive clinical trial landscape in myositis. While these are exciting times for the myositis field, we have a number of concerns about the design and conduct of the myositis trials. These include competitive landscape, lengthy placebo arms, underrepresentation of minority groups among participants, use of patient reported outcome measures with limited/no data on validity in myositis, antiquated disease classification criteria, and unclear performance of the ACR/EULAR Myositis Response Criteria in skin-predominant patients despite inclusion of these patients in trials. In this viewpoint, we further discuss these concerns and offer potential solutions such as including patient perspectives in the trial design and adoption of innovative frameworks.
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Affiliation(s)
- Didem Saygin
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Victoria Werth
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania and Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA
| | - Julie J Paik
- Department of Medicine, Division of Rheumatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jin Kyun Park
- Department of Internal Medicine, Division of Rheumatology, Seoul National University Hospital and College of Medicine, Seoul, Korea (the Republic of)
| | - Merrilee Needham
- Department of Neurology, Fiona Stanley Hospital, IIID Murdoch University and University of Notre Dame, Perth, Western Australia, Australia
| | - Ingrid E Lundberg
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Lisa Christopher-Stine
- Department of Medicine, Division of Rheumatology, Johns Hopkins University, Baltimore, Maryland, USA
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Li X, Bedlack R. Evaluating emerging drugs in phase II & III for the treatment of amyotrophic lateral sclerosis. Expert Opin Emerg Drugs 2024; 29:93-102. [PMID: 38516735 DOI: 10.1080/14728214.2024.2333420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 03/18/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Amyotrophic Lateral Sclerosis is a rapidly progressive motor neuron disorder causing severe disability and premature death. Owing to the advances in uncovering ALS pathophysiology, efficient clinical trial design and research advocacy program, several disease-modifying drugs have been approved for treating ALS. Despite this progress, ALS remains a rapidly disabling and life shortening condition. There is a critical need for more effective therapies. AREAS COVERED Here, we reviewed the emerging ALS therapeutics undergoing phase II & III clinical trials. To identify the investigational drugs, we searched ALS and phase II/III trials that are active and recruiting or not yet recruiting on clinicaltrials.gov and Pharmaprojects database. EXPERT OPINION The current pipeline is larger and more diverse than ever, with drugs targeting potential genetic and retroviral causes of ALS and drugs targeting a wide array of downstream pathways, including RNA metabolism, protein aggregation, integrated stress response and neuroinflammation.We remain most excited about those that target direct causes of ALS, e.g. antisense oligonucleotides targeting causative genes. Drugs that eliminate abnormal protein aggregates are also up-and-coming. Eventually, because of the heterogeneity of ALS pathophysiology, biomarkers that determine which biological events are most important for an individual ALS patient are needed.
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Affiliation(s)
- Xiaoyan Li
- Department of Neurology, Duke University, Durham, NC, USA
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Tondo G, De Marchi F, Bonardi F, Menegon F, Verrini G, Aprile D, Anselmi M, Mazzini L, Comi C. Novel Therapeutic Strategies in Alzheimer's Disease: Pitfalls and Challenges of Anti-Amyloid Therapies and Beyond. J Clin Med 2024; 13:3098. [PMID: 38892809 PMCID: PMC11172489 DOI: 10.3390/jcm13113098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 05/21/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Alzheimer's disease (AD) causes a significant challenge to global healthcare systems, with limited effective treatments available. This review examines the landscape of novel therapeutic strategies for AD, focusing on the shortcomings of traditional therapies against amyloid-beta (Aβ) and exploring emerging alternatives. Despite decades of research emphasizing the role of Aβ accumulation in AD pathogenesis, clinical trials targeting Aβ have obtained disappointing results, highlighting the complexity of AD pathophysiology and the need for investigating other therapeutic approaches. In this manuscript, we first discuss the challenges associated with anti-Aβ therapies, including limited efficacy and potential adverse effects, underscoring the necessity of exploring alternative mechanisms and targets. Thereafter, we review promising non-Aβ-based strategies, such as tau-targeted therapies, neuroinflammation modulation, and gene and stem cell therapy. These approaches offer new avenues for AD treatment by addressing additional pathological hallmarks and downstream effects beyond Aβ deposition.
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Affiliation(s)
- Giacomo Tondo
- Neurology Unit, Department of Translational Medicine, Maggiore della Carità Hospital, University of Piemonte Orientale, 28100 Novara, Italy; (G.T.); (F.B.); (F.M.); (G.V.); (D.A.); (M.A.); (L.M.)
| | - Fabiola De Marchi
- Neurology Unit, Department of Translational Medicine, Maggiore della Carità Hospital, University of Piemonte Orientale, 28100 Novara, Italy; (G.T.); (F.B.); (F.M.); (G.V.); (D.A.); (M.A.); (L.M.)
| | - Francesca Bonardi
- Neurology Unit, Department of Translational Medicine, Maggiore della Carità Hospital, University of Piemonte Orientale, 28100 Novara, Italy; (G.T.); (F.B.); (F.M.); (G.V.); (D.A.); (M.A.); (L.M.)
| | - Federico Menegon
- Neurology Unit, Department of Translational Medicine, Maggiore della Carità Hospital, University of Piemonte Orientale, 28100 Novara, Italy; (G.T.); (F.B.); (F.M.); (G.V.); (D.A.); (M.A.); (L.M.)
| | - Gaia Verrini
- Neurology Unit, Department of Translational Medicine, Maggiore della Carità Hospital, University of Piemonte Orientale, 28100 Novara, Italy; (G.T.); (F.B.); (F.M.); (G.V.); (D.A.); (M.A.); (L.M.)
| | - Davide Aprile
- Neurology Unit, Department of Translational Medicine, Maggiore della Carità Hospital, University of Piemonte Orientale, 28100 Novara, Italy; (G.T.); (F.B.); (F.M.); (G.V.); (D.A.); (M.A.); (L.M.)
| | - Matteo Anselmi
- Neurology Unit, Department of Translational Medicine, Maggiore della Carità Hospital, University of Piemonte Orientale, 28100 Novara, Italy; (G.T.); (F.B.); (F.M.); (G.V.); (D.A.); (M.A.); (L.M.)
| | - Letizia Mazzini
- Neurology Unit, Department of Translational Medicine, Maggiore della Carità Hospital, University of Piemonte Orientale, 28100 Novara, Italy; (G.T.); (F.B.); (F.M.); (G.V.); (D.A.); (M.A.); (L.M.)
| | - Cristoforo Comi
- Neurology Unit, Department of Translational Medicine, Sant’Andrea Hospital, University of Piemonte Orientale, Corso Abbiate 21, 13100 Vercelli, Italy;
- Interdisciplinary Research Center of Autoimmune Diseases (IRCAD), University of Piemonte Orientale, 28100 Novara, Italy
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Pennuto M, Pradat PF, Sorarù G, Greensmith L. 271st ENMC international workshop: Towards a unifying effort to fight Kennedy's disease. 20-22 October 2023, Hoofddorp, Netherlands. Neuromuscul Disord 2024; 38:8-19. [PMID: 38552412 DOI: 10.1016/j.nmd.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/05/2024] [Accepted: 03/08/2024] [Indexed: 05/03/2024]
Abstract
The workshop held in the Netherlands from October 20-22, 2023, united 27 scientists from academia, healthcare, and industry representing 11 countries, alongside four patient and charity representatives. Focused on Kennedy's Disease (KD), also known as spinal and bulbar muscular atrophy (SBMA), the workshop aimed to consolidate knowledge, align on clinical trial designs, and promote participative medicine for effective treatments. Discussions emphasized KD's molecular mechanisms, highlighting its status as a neuromuscular disorder with motor neuron degeneration. Strategies for therapeutic intervention, including AR activity modulation and targeting post-translational modifications, were proposed. The need for diagnostic, prognostic, and target engagement biomarkers was stressed. Challenges in patient stratification and clinical trial recruitment were acknowledged, with the International KD/SBMA Registry praised for its role. The workshop concluded with a patient-focused session, underscoring challenges in KD diagnosis and the vital support provided by patient associations.
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Affiliation(s)
- M Pennuto
- Department of Biomedical Sciences (DBS), University of Padova, 35131 Padova, Italy; Veneto Institute of Molecular Medicine (VIMM), Padova 35100, Italy.
| | - P F Pradat
- Département de Neurologie, AP-HP, Groupe hospitalier Pitié-Salpêtrière, F-75013 Paris, France; Sorbonne Université, UPMC University Paris 06, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale (LIB), 75013 Paris, France
| | - G Sorarù
- Department of Neurosciences, University of Padova, Padova, Italy
| | - L Greensmith
- Department of Neuromuscular Diseases, UCL Institute of Neurology, London, UK.
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Montesi SB, Gomez CR, Beers M, Brown R, Chattopadhyay I, Flaherty KR, Garcia CK, Gomperts B, Hariri LP, Hogaboam CM, Jenkins RG, Kaminski N, Kim GHJ, Königshoff M, Kolb M, Kotton DN, Kropski JA, Lasky J, Magin CM, Maher TM, McCormick M, Moore BB, Nickerson-Nutter C, Oldham J, Podolanczuk AJ, Raghu G, Rosas I, Rowe SM, Schmidt WT, Schwartz D, Shore JE, Spino C, Craig JM, Martinez FJ. Pulmonary Fibrosis Stakeholder Summit: A Joint NHLBI, Three Lakes Foundation, and Pulmonary Fibrosis Foundation Workshop Report. Am J Respir Crit Care Med 2024; 209:362-373. [PMID: 38113442 PMCID: PMC10878386 DOI: 10.1164/rccm.202307-1154ws] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 12/19/2023] [Indexed: 12/21/2023] Open
Abstract
Despite progress in elucidation of disease mechanisms, identification of risk factors, biomarker discovery, and the approval of two medications to slow lung function decline in idiopathic pulmonary fibrosis and one medication to slow lung function decline in progressive pulmonary fibrosis, pulmonary fibrosis remains a disease with a high morbidity and mortality. In recognition of the need to catalyze ongoing advances and collaboration in the field of pulmonary fibrosis, the NHLBI, the Three Lakes Foundation, and the Pulmonary Fibrosis Foundation hosted the Pulmonary Fibrosis Stakeholder Summit on November 8-9, 2022. This workshop was held virtually and was organized into three topic areas: 1) novel models and research tools to better study pulmonary fibrosis and uncover new therapies, 2) early disease risk factors and methods to improve diagnosis, and 3) innovative approaches toward clinical trial design for pulmonary fibrosis. In this workshop report, we summarize the content of the presentations and discussions, enumerating research opportunities for advancing our understanding of the pathogenesis, treatment, and outcomes of pulmonary fibrosis.
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Affiliation(s)
| | - Christian R. Gomez
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Michael Beers
- Pulmonary and Critical Care Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert Brown
- Program in Neurotherapeutics, University of Massachusetts Chan Medical School, Worchester, Massachusetts
| | | | | | - Christine Kim Garcia
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York
| | | | - Lida P. Hariri
- Division of Pulmonary and Critical Care Medicine and
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Cory M. Hogaboam
- Women’s Guild Lung Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - R. Gisli Jenkins
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Naftali Kaminski
- Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Grace Hyun J. Kim
- Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, David Geffen School of Medicine, and
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Melanie Königshoff
- Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Martin Kolb
- Division of Respirology, McMaster University, Hamilton, Ontario, Canada
| | - Darrell N. Kotton
- Center for Regenerative Medicine, Boston University and Boston Medical Center, Boston, Massachusetts
| | - Jonathan A. Kropski
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joseph Lasky
- Pulmonary Fibrosis Foundation, Chicago, Illinois
- Department of Medicine, Tulane University, New Orleans, Louisiana
| | - Chelsea M. Magin
- Department of Bioengineering
- Department of Pediatrics
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, and
| | - Toby M. Maher
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | | | | | | | - Anna J. Podolanczuk
- Division of Pulmonary and Critical Care, Weill Cornell Medical College, New York, New York
| | - Ganesh Raghu
- Division of Pulmonary, Sleep and Critical Care Medicine, University of Washington, Seattle, Washington
| | - Ivan Rosas
- Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas; and
| | - Steven M. Rowe
- Department of Medicine and
- Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - David Schwartz
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Cathie Spino
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - J. Matthew Craig
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Fernando J. Martinez
- Division of Pulmonary and Critical Care, Weill Cornell Medical College, New York, New York
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10
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Dey B, Kumar A, Patel AB. Pathomechanistic Networks of Motor System Injury in Amyotrophic Lateral Sclerosis. Curr Neuropharmacol 2024; 22:1778-1806. [PMID: 37622689 DOI: 10.2174/1570159x21666230824091601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/25/2023] [Accepted: 06/06/2023] [Indexed: 08/26/2023] Open
Abstract
Amyotrophic Lateral Sclerosis (ALS) is the most common, adult-onset, progressive motor neurodegenerative disorder that results in death within 3 years of the clinical diagnosis. Due to the clinicopathological heterogeneity, any reliable biomarkers for diagnosis or prognosis of ALS have not been identified till date. Moreover, the only three clinically approved treatments are not uniformly effective in slowing the disease progression. Over the last 15 years, there has been a rapid advancement in research on the complex pathomechanistic landscape of ALS that has opened up new avenues for successful clinical translation of targeted therapeutics. Multiple studies suggest that the age-dependent interaction of risk-associated genes with environmental factors and endogenous modifiers is critical to the multi-step process of ALS pathogenesis. In this review, we provide an updated discussion on the dysregulated cross-talk between intracellular homeostasis processes, the unique molecular networks across selectively vulnerable cell types, and the multisystemic nature of ALS pathomechanisms. Importantly, this work highlights the alteration in epigenetic and epitranscriptomic landscape due to gene-environment interactions, which have been largely overlooked in the context of ALS pathology. Finally, we suggest that precision medicine research in ALS will be largely benefitted from the stratification of patient groups based on the clinical phenotype, onset and progression, genome, exposome, and metabolic identities.
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Affiliation(s)
- Bedaballi Dey
- CSIR-Centre for Cellular and Molecular Biology (CSIR-CCMB), Hyderabad 500007, Telangana, India
- AcSIR-Academy of Scientific and Innovative Research, Ghaziabad 201002, Uttar Pradesh, India
| | - Arvind Kumar
- CSIR-Centre for Cellular and Molecular Biology (CSIR-CCMB), Hyderabad 500007, Telangana, India
- AcSIR-Academy of Scientific and Innovative Research, Ghaziabad 201002, Uttar Pradesh, India
| | - Anant Bahadur Patel
- CSIR-Centre for Cellular and Molecular Biology (CSIR-CCMB), Hyderabad 500007, Telangana, India
- AcSIR-Academy of Scientific and Innovative Research, Ghaziabad 201002, Uttar Pradesh, India
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11
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Mehta AR, Carpenter JR, Nicholas JM, Chataway J, Virgo B, Parmar MKB, Chandran S, Pal S. The role of placebo control in clinical trials for neurodegenerative diseases. Nat Med 2023; 29:2682-2683. [PMID: 37710137 DOI: 10.1038/d41591-023-00080-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
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12
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Abstract
Although the past two decades have produced exciting discoveries in the genetics and pathology of amyotrophic lateral sclerosis (ALS), progress in developing an effective therapy remains slow. This review summarizes the critical discoveries and outlines the advances in disease characterization, diagnosis, imaging, and biomarkers, along with the current status of approaches to ALS care and treatment. Additional knowledge of the factors driving disease progression and heterogeneity will hopefully soon transform the care for patients with ALS into an individualized, multi-prong approach able to prevent disease progression sufficiently to allow for a dignified life with limited disability.
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Affiliation(s)
- Hristelina Ilieva
- Jefferson Weinberg ALS Center, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Justin Kwan
- National Institute of Neurological Disorders and Stroke, National Institute of Health, Bethesda, MD, USA
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13
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Boxer AL, Sperling R. Accelerating Alzheimer's therapeutic development: The past and future of clinical trials. Cell 2023; 186:4757-4772. [PMID: 37848035 PMCID: PMC10625460 DOI: 10.1016/j.cell.2023.09.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 08/03/2023] [Accepted: 09/22/2023] [Indexed: 10/19/2023]
Abstract
Alzheimer's disease (AD) research has entered a new era with the recent positive phase 3 clinical trials of the anti-Aβ antibodies lecanemab and donanemab. Why did it take 30 years to achieve these successes? Developing potent therapies for reducing fibrillar amyloid was key, as was selection of patients at relatively early stages of disease. Biomarkers of the target pathologies, including amyloid and tau PET, and insights from past trials were also critical to the recent successes. Moving forward, the challenge will be to develop more efficacious therapies with greater efficiency. Novel trial designs, including combination therapies and umbrella and basket protocols, will accelerate clinical development. Better diversity and inclusivity of trial participants are needed, and blood-based biomarkers may help to improve access for medically underserved groups. Incentivizing innovation in both academia and industry through public-private partnerships, collaborative mechanisms, and the creation of new career paths will be critical to build momentum in these exciting times.
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Affiliation(s)
- Adam L Boxer
- Memory and Aging Center, Department of Neurology, Weill Institute of Neuroscience, University of California, San Francisco, San Francisco, CA, USA.
| | - Reisa Sperling
- Center for Alzheimer Research and Treatment, Department of Neurology, MassGeneral Brigham, Harvard Medical School, Boston, MA, USA
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14
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Rogers ML, Schultz DW, Karnaros V, Shepheard SR. Urinary biomarkers for amyotrophic lateral sclerosis: candidates, opportunities and considerations. Brain Commun 2023; 5:fcad287. [PMID: 37946793 PMCID: PMC10631861 DOI: 10.1093/braincomms/fcad287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/23/2023] [Accepted: 10/24/2023] [Indexed: 11/12/2023] Open
Abstract
Amyotrophic lateral sclerosis is a relentless neurodegenerative disease that is mostly fatal within 3-5 years and is diagnosed on evidence of progressive upper and lower motor neuron degeneration. Around 15% of those with amyotrophic lateral sclerosis also have frontotemporal degeneration, and gene mutations account for ∼10%. Amyotrophic lateral sclerosis is a variable heterogeneous disease, and it is becoming increasingly clear that numerous different disease processes culminate in the final degeneration of motor neurons. There is a profound need to clearly articulate and measure pathological process that occurs. Such information is needed to tailor treatments to individuals with amyotrophic lateral sclerosis according to an individual's pathological fingerprint. For new candidate therapies, there is also a need for methods to select patients according to expected treatment outcomes and measure the success, or not, of treatments. Biomarkers are essential tools to fulfil these needs, and urine is a rich source for candidate biofluid biomarkers. This review will describe promising candidate urinary biomarkers of amyotrophic lateral sclerosis and other possible urinary candidates in future areas of investigation as well as the limitations of urinary biomarkers.
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Affiliation(s)
- Mary-Louise Rogers
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide 5042, South Australia, Australia
| | - David W Schultz
- Neurology Department and MND Clinic, Flinders Medical Centre, Adelaide 5042, South Australia, Australia
| | - Vassilios Karnaros
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide 5042, South Australia, Australia
| | - Stephanie R Shepheard
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide 5042, South Australia, Australia
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15
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Agarwal A, Marion J, Nagy P, Robinson M, Walkey A, Sevransky J. How Electronic Medical Record Integration Can Support More Efficient Critical Care Clinical Trials. Crit Care Clin 2023; 39:733-749. [PMID: 37704337 DOI: 10.1016/j.ccc.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Large volumes of data are collected on critically ill patients, and using data science to extract information from the electronic medical record (EMR) and to inform the design of clinical trials represents a new opportunity in critical care research. Using improved methods of phenotyping critical illnesses, subject identification and enrollment, and targeted treatment group assignment alongside newer trial designs such as adaptive platform trials can increase efficiency while lowering costs. Some tools such as the EMR to automate data collection are already in use. Refinement of data science approaches in critical illness research will allow for better clinical trials and, ultimately, improved patient outcomes.
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Affiliation(s)
- Ankita Agarwal
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA
| | | | - Paul Nagy
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew Robinson
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allan Walkey
- Department of Medicine - Section of Pulmonary, Allergy, Critical Care and Sleep Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jonathan Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA.
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16
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Quintana M, Saville BR, Vestrucci M, Detry MA, Chibnik L, Shefner J, Berry JD, Chase M, Andrews J, Sherman AV, Yu H, Drake K, Cudkowicz M, Paganoni S, Macklin EA. Design and Statistical Innovations in a Platform Trial for Amyotrophic Lateral Sclerosis. Ann Neurol 2023; 94:547-560. [PMID: 37245090 DOI: 10.1002/ana.26714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 05/29/2023]
Abstract
Platform trials allow efficient evaluation of multiple interventions for a specific disease. The HEALEY ALS Platform Trial is testing multiple investigational products in parallel and sequentially in persons with amyotrophic lateral sclerosis (ALS) with the goal of rapidly identifying novel treatments to slow disease progression. Platform trials have considerable operational and statistical efficiencies compared with typical randomized controlled trials due to their use of shared infrastructure and shared control data. We describe the statistical approaches required to achieve the objectives of a platform trial in the context of ALS. This includes following regulatory guidance for the disease area of interest and accounting for potential differences in outcomes of participants within the shared control (potentially due to differences in time of randomization, mode of administration, and eligibility criteria). Within the HEALEY ALS Platform Trial, the complex statistical objectives are met using a Bayesian shared parameter analysis of function and survival. This analysis serves to provide a common integrated estimate of treatment benefit, overall slowing in disease progression, as measured by function and survival while accounting for potential differences in the shared control group using Bayesian hierarchical modeling. Clinical trial simulation is used to provide a better understanding of this novel analysis method and complex design. ANN NEUROL 2023;94:547-560.
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Affiliation(s)
| | - Benjamin R Saville
- Berry Consultants, Austin, Texas, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Lori Chibnik
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy Shefner
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - James D Berry
- Sean M. Healey & AMG Center for ALS at Mass General, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Marianne Chase
- Sean M. Healey & AMG Center for ALS at Mass General, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Jinsy Andrews
- Neurological Institute of New York, Columbia University, New York, New York, USA
| | - Alexander V Sherman
- Sean M. Healey & AMG Center for ALS at Mass General, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Hong Yu
- Sean M. Healey & AMG Center for ALS at Mass General, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Kristin Drake
- Sean M. Healey & AMG Center for ALS at Mass General, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Merit Cudkowicz
- Sean M. Healey & AMG Center for ALS at Mass General, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Sabrina Paganoni
- Sean M. Healey & AMG Center for ALS at Mass General, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | - Eric A Macklin
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona, USA
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17
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Kelly-Hedrik M, Abd-El-Barr MM, Aarabi B, Curt A, Howley SP, Harrop JS, Kirshblum S, Neal CJ, Noonan V, Park C, Ugiliweneza B, Tator C, Toups EG, Fehlings MG, Williamson T, Guest JD. Importance of Prospective Registries and Clinical Research Networks in the Evolution of Spinal Cord Injury Care. J Neurotrauma 2023; 40:1834-1848. [PMID: 36576020 DOI: 10.1089/neu.2022.0450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Only 100 years ago, traumatic spinal cord injury (SCI) was commonly lethal. Today, most people who sustain SCI survive with continual efforts to improve their quality of life and neurological outcomes. SCI epidemiology is changing as preventative interventions reduce injuries in younger individuals, and there is an increased incidence of incomplete injuries in aging populations. Early treatment has become more intensive with decompressive surgery and proactive interventions to improve spinal cord perfusion. Accurate data, including specialized outcome measures, are crucial to understanding the impact of epidemiological and treatment trends. Dedicated SCI clinical research and data networks and registries have been established in the United States, Canada, Europe, and several other countries. We review four registry networks: the North American Clinical Trials Network (NACTN) SCI Registry, the National Spinal Cord Injury Model Systems (SCIMS) Database, the Rick Hansen SCI Registry (RHSCIR), and the European Multi-Center Study about Spinal Cord Injury (EMSCI). We compare the registries' focuses, data platforms, advanced analytics use, and impacts. We also describe how registries' data can be combined with electronic health records (EHRs) or shared using federated analysis to protect registrants' identities. These registries have identified changes in epidemiology, recovery patterns, complication incidence, and the impact of practice changes such as early decompression. They've also revealed latent disease-modifying factors, helped develop clinical trial stratification models, and served as matched control groups in clinical trials. Advancing SCI clinical science for personalized medicine requires advanced analytical techniques, including machine learning, counterfactual analysis, and the creation of digital twins. Registries and other data sources help drive innovation in SCI clinical science.
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Affiliation(s)
| | | | - Bizhan Aarabi
- University of Maryland School of Medicine, Maryland, USA
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Susan P Howley
- Christopher & Dana Reeve Foundation, Short Hills, New Jersey, USA
| | - James S Harrop
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Steven Kirshblum
- Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
- Kessler Foundation, West Orange, New Jersey, USA
| | - Christopher J Neal
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Vanessa Noonan
- Praxis Spinal Cord Institute, Vancouver, British Columbia, Canada
| | - Christine Park
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Charles Tator
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth G Toups
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Theresa Williamson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James D Guest
- Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami, Miami, USA
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18
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Schoenmakers DH, Leferink PS, Vanderver A, Bonkowsky JL, Krägeloh-Mann I, Bernard G, Bertini E, Fatemi A, Fogel BL, Wolf NI, Skwirut D, Buck A, Holberg B, Saunier-Vivar EF, Rauner R, Dekker H, van Bokhoven P, Stellingwerff MD, Berkhof J, van der Knaap MS. Core protocol development for phase 2/3 clinical trials in the leukodystrophy vanishing white matter: a consensus statement by the VWM consortium and patient advocates. BMC Neurol 2023; 23:305. [PMID: 37592248 PMCID: PMC10433679 DOI: 10.1186/s12883-023-03354-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 08/02/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND The leukodystrophy "Vanishing White Matter" (VWM) is an orphan disease with neurological decline and high mortality. Currently, VWM has no approved treatments, but advances in understanding pathophysiology have led to identification of promising therapies. Several investigational medicinal products are either in or about to enter clinical trial phase. Clinical trials in VWM pose serious challenges, as VWM has an episodic disease course; disease phenotype is highly heterogeneous and predictable only for early onset; and study power is limited by the small patient numbers. To address these challenges and accelerate therapy delivery, the VWM Consortium, a group of academic clinicians with expertise in VWM, decided to develop a core protocol to function as a template for trials, to improve trial design and facilitate sharing of control data, while permitting flexibility regarding other trial details. Overall aims of the core protocol are to collect safety, tolerability, and efficacy data for treatment assessment and marketing authorization. METHODS To develop the core protocol, the VWM Consortium designated a committee, including clinician members of the VWM Consortium, family and patient group advocates, and experts in statistics, clinical trial design and alliancing with industries. We drafted three age-specific protocols, to stratify into more homogeneous patient groups, of ages ≥ 18 years, ≥ 6 to < 18 years and < 6 years. We chose double-blind, randomized, placebo-controlled design for patients aged ≥ 6 years; and open-label non-randomized natural-history-controlled design for patients < 6 years. The protocol describes study populations, age-specific endpoints, inclusion and exclusion criteria, study schedules, sample size determinations, and statistical considerations. DISCUSSION The core protocol provides a shared uniformity across trials, enables a pool of shared controls, and reduces the total number of patients necessary per trial, limiting the number of patients on placebo. All VWM clinical trials are suggested to adhere to the core protocol. Other trial components such as choice of primary outcome, pharmacokinetics, pharmacodynamics, and biomarkers are flexible and unconstrained by the core protocol. Each sponsor is responsible for their trial execution, while the control data are handled by a shared research organization. This core protocol benefits the efficiency of parallel and consecutive trials in VWM, and we hope accelerates time to availability of treatments for VWM. TRIAL REGISTRATION NA. From a scientific and ethical perspective, it is strongly recommended that all interventional trials using this core protocol are registered in a clinical trial register.
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Affiliation(s)
- Daphne H Schoenmakers
- Department of Child Neurology, Emma's Children's Hospital, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam Leukodystrophy Center, Amsterdam Neuroscience, Cellular & Molecular Mechanisms, Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, Platform "Medicine for Society", Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Prisca S Leferink
- IXA Neuroscience, Amsterdam Neuroscience, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Adeline Vanderver
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Joshua L Bonkowsky
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Ingeborg Krägeloh-Mann
- Department of Developmental and Child Neurology, Social Pediatrics, University Children's Hospital Tübingen, Tübingen, Germany
| | - Geneviève Bernard
- Departments of Neurology and Neurosurgery, Pediatrics and Human Genetics, McGill University; Department Specialized Medicine, Division of Medical Genetics, McGill University Health Center, Montreal, Canada
- Child Health and Human Development Program, Research Institute of the McGill University Health Center, Montreal, Canada
| | - Enrico Bertini
- Research Unit of Neuromuscular and Neurodegenerative Diseases, Translational Pediatrics and Clinical Genetics Research Division, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Ali Fatemi
- Kennedy Krieger Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Brent L Fogel
- Los Angeles David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Nicole I Wolf
- Department of Child Neurology, Emma's Children's Hospital, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam Leukodystrophy Center, Amsterdam Neuroscience, Cellular & Molecular Mechanisms, Amsterdam, The Netherlands
| | - Donna Skwirut
- United Leukodystrophy Foundation, DeKalb Illinois, USA
- VWM Families Foundation, Greenwhich, CT, USA
| | | | | | - Elise F Saunier-Vivar
- Research Department, European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France
| | - Robert Rauner
- United Leukodystrophy Foundation, DeKalb Illinois, USA
| | - Hanka Dekker
- Vereniging Volwassenen, Kinderen en Stofwisselingsziekten, Zwolle, The Netherlands
| | - Pieter van Bokhoven
- IXA Neuroscience, Amsterdam Neuroscience, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Menno D Stellingwerff
- Department of Child Neurology, Emma's Children's Hospital, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam Leukodystrophy Center, Amsterdam Neuroscience, Cellular & Molecular Mechanisms, Amsterdam, The Netherlands
| | - Johannes Berkhof
- Department of Epidemiology and Data Science, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Marjo S van der Knaap
- Department of Child Neurology, Emma's Children's Hospital, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands.
- Amsterdam Leukodystrophy Center, Amsterdam Neuroscience, Cellular & Molecular Mechanisms, Amsterdam, The Netherlands.
- Department of Integrative Neurophysiology, Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, The Netherlands.
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Vucic S, Kiernan MC. Nanocrystalline gold (CNM-Au8): a novel bioenergetic treatment for ALS. Expert Opin Investig Drugs 2023; 32:783-785. [PMID: 37740686 DOI: 10.1080/13543784.2023.2263368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/22/2023] [Indexed: 09/25/2023]
Affiliation(s)
- Steve Vucic
- Brain and Nerve Research Center, The University of Sydney, Sydney, Australia
| | - Matthew C Kiernan
- Brain and Mind Centre, The University of Sydney; and Department of Neurology, Sydney, NSW, Australia
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Comi G, Leocani L, Tagliavini F. Preserving the brain: forum on neurodegenerative diseases. Neurol Sci 2023; 44:2613-2616. [PMID: 37002504 PMCID: PMC10257600 DOI: 10.1007/s10072-023-06721-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Affiliation(s)
- Giancarlo Comi
- Department of Neurorehabilitation Sciences, Casa Di Cura Igea, Milan, Italy.
| | - Letizia Leocani
- University Vita-Salute San Raffaele and Experimental Neurophysiology Unit, Institute of Experimental Neurology (INSPE), Scientific Institute San Raffaele, Milan, Italy
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21
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Bireley JD, Morren JA. CNM-Au8: an experimental agent for the treatment of amyotrophic lateral sclerosis (ALS). Expert Opin Investig Drugs 2023; 32:677-683. [PMID: 37642362 DOI: 10.1080/13543784.2023.2252738] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/21/2023] [Accepted: 08/24/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Two established disease-specific therapies for the treatment of amyotrophic lateral sclerosis (ALS) are riluzole and edaravone. Limitations of these medications include minimal progression slowing or survival benefit, and effectiveness only in selected populations, particularly for edaravone. AMX0035 and tofersen received US FDA approval in September 2022 and April 2023, respectively. However, phase 3 trials, further examining both medications' efficacy, are ongoing. CNM-Au8 is an efficient catalyst of energy metabolism and is therefore a potential disease-modifying treatment for ALS, a neurodegenerative condition in which there is bioenergetics impairment. AREAS COVERED In this review, we provide an overview of the current ALS treatment market, followed by a description of the pharmacodynamics and pharmacokinetics of CNM-Au8. The main preclinical and available early clinical evidence of CNM-Au8 is then described, as well as its potential as an ALS treatment. EXPERT OPINION Oral treatment with CNM-Au8 failed to meet primary clinical and electrodiagnostic endpoints in phase 2/3 clinical trials. Despite this failure, a number of exploratory endpoints included in phase 2/3 trials suggest CNM-Au8 has the potential to significantly slow clinical worsening, improve quality of life, and prolong survival in ALS. Further study of CNM-Au8 in a phase 3 clinical trial is currently underway.
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Affiliation(s)
- J Daniel Bireley
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John A Morren
- Neuromuscular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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22
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Vucic S, Menon P, Huynh W, Mahoney C, Ho KS, Hartford A, Rynders A, Evan J, Evan J, Ligozio S, Glanzman R, Hotchkin MT, Kiernan MC. Efficacy and safety of CNM-Au8 in amyotrophic lateral sclerosis (RESCUE-ALS study): a phase 2, randomised, double-blind, placebo-controlled trial and open label extension. EClinicalMedicine 2023; 60:102036. [PMID: 37396808 PMCID: PMC10314176 DOI: 10.1016/j.eclinm.2023.102036] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/17/2023] [Accepted: 05/19/2023] [Indexed: 07/04/2023] Open
Abstract
Background CNM-Au8® is a catalytically-active gold nanocrystal neuroprotective agent that enhances intracellular energy metabolism and reduces oxidative stress. The phase 2, randomised, double-blind, placebo-controlled trial and open label extension RESCUE-ALS trial evaluated the efficacy and safety of CNM-Au8 for treatment of amyotrophic lateral sclerosis (ALS). Methods RESCUE-ALS and its long-term open label extension (OLE) were conducted at two multidisciplinary ALS clinics located in Sydney, Australia: (i) the Brain and Mind Centre and (ii) Westmead Hospital. The double-blind portion of RESCUE-ALS was conducted from January 16, 2020 (baseline visit, first-patient first-visit (FPFV)) through July 13, 2021 (double-blind period, last-patient last-visit (LPLV)). Participants (N = 45) were randomised 1:1 to receive 30 mg of CNM-Au8 or matching placebo daily over 36 weeks in addition to background standard of care, riluzole. The primary outcome was mean percent change in summed motor unit number index (MUNIX), a sensitive neurophysiological biomarker of lower motor neuron function. Change in total (or summated) MUNIX score and change in forced vital capacity (FVC) were secondary outcome measures. ALS disease progression events, ALS Functional Rating Scale (ALSFRS-R) change, change in quality of life (ALSSQOL-SF) were assessed as exploratory outcome measures. Long-term survival evaluated vital status of original active versus placebo randomisation for all participants through at least 12 months following last-patient last-visit (LPLV) of the double-blind period. RESCUE-ALS and the open label study are registered in clinicaltrials.gov with registration numbers NCT04098406 and NCT05299658, respectively. Findings In the intention-to-treat (ITT) population, there was no significant difference in the summated MUNIX score percent change (LS mean difference: 7.7%, 95% CI: -11.9 to 27.3%, p = 0.43), total MUNIX score change (18.8, 95% CI: -56.4 to 94.0), or FVC change (LS mean difference: 3.6, 95% CI: -12.4 to 19.7) between the active and placebo treated groups at week 36. In contrast, survival analyses through 12-month LPLV demonstrated a 60% reduction in all-cause mortality with CNM-Au8 treatment [hazard ratio = 0.408 (95% Wald CI: 0.166 to 1.001, log-rank p = 0.0429). 36 participants entered the open label extension (OLE), and those initially randomised to CNM-Au8 exhibited a slower rate of disease progression, as measured by time to the occurrence of death, tracheostomy, initiation of non-invasive ventilatory support, or gastrostomy tube placement. CNM-Au8 was well-tolerated, and no safety signals were observed. Interpretation CNM-Au8, in combination with riluzole, was well-tolerated in ALS with no identified safety signals. While the primary and secondary outcomes of this trial were not significant, the clinically meaningful exploratory results support further investigation of CNM-Au8 in ALS. Funding The RESCUE-ALS was substantially funded by a grant from FightMND. Additional funding was provided by Clene Australia Pty Ltd.
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Affiliation(s)
- Steve Vucic
- Brain and Nerve Research Centre, Concord Clinical School and Department of Neurology, Concord Repatriation General Hospital, The University of Sydney, Sydney, Australia
| | - Parvathi Menon
- Brain and Nerve Research Centre, Concord Clinical School and Department of Neurology, Concord Repatriation General Hospital, The University of Sydney, Sydney, Australia
| | - William Huynh
- Brain and Mind Centre, University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Colin Mahoney
- Brain and Mind Centre, University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Karen S. Ho
- Clene Nanomedicine, Inc., Salt Lake City, UT, USA
| | | | | | - Jacob Evan
- Clene Nanomedicine, Inc., Salt Lake City, UT, USA
| | - Jeremy Evan
- Clene Nanomedicine, Inc., Salt Lake City, UT, USA
| | | | | | | | - Matthew C. Kiernan
- Brain and Mind Centre, University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
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23
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Fisher EM, Greensmith L, Malaspina A, Fratta P, Hanna MG, Schiavo G, Isaacs AM, Orrell RW, Cunningham TJ, Arozena AA. Opinion: more mouse models and more translation needed for ALS. Mol Neurodegener 2023; 18:30. [PMID: 37143081 PMCID: PMC10161557 DOI: 10.1186/s13024-023-00619-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 04/11/2023] [Indexed: 05/06/2023] Open
Abstract
Amyotrophic lateral sclerosis is a complex disorder most of which is 'sporadic' of unknown origin but approximately 10% is familial, arising from single mutations in any of more than 30 genes. Thus, there are more than 30 familial ALS subtypes, with different, often unknown, molecular pathologies leading to a complex constellation of clinical phenotypes. We have mouse models for many genetic forms of the disorder, but these do not, on their own, necessarily show us the key pathological pathways at work in human patients. To date, we have no models for the 90% of ALS that is 'sporadic'. Potential therapies have been developed mainly using a limited set of mouse models, and through lack of alternatives, in the past these have been tested on patients regardless of aetiology. Cancer researchers have undertaken therapy development with similar challenges; they have responded by producing complex mouse models that have transformed understanding of pathological processes, and they have implemented patient stratification in multi-centre trials, leading to the effective translation of basic research findings to the clinic. ALS researchers have successfully adopted this combined approach, and now to increase our understanding of key disease pathologies, and our rate of progress for moving from mouse models to mechanism to ALS therapies we need more, innovative, complex mouse models to address specific questions.
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Affiliation(s)
- Elizabeth M.C. Fisher
- UCL Queen Square Motor Neuron Disease Centre, UCL Queen Square Institute of Neurology, University College London, Queen Square, London, WC1N 3BG UK
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, University College London, Queen Square, London, WC1N 3BG UK
| | - Linda Greensmith
- UCL Queen Square Motor Neuron Disease Centre, UCL Queen Square Institute of Neurology, University College London, Queen Square, London, WC1N 3BG UK
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, University College London, Queen Square, London, WC1N 3BG UK
| | - Andrea Malaspina
- UCL Queen Square Motor Neuron Disease Centre, UCL Queen Square Institute of Neurology, University College London, Queen Square, London, WC1N 3BG UK
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, University College London, Queen Square, London, WC1N 3BG UK
| | - Pietro Fratta
- UCL Queen Square Motor Neuron Disease Centre, UCL Queen Square Institute of Neurology, University College London, Queen Square, London, WC1N 3BG UK
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, University College London, Queen Square, London, WC1N 3BG UK
| | - Michael G. Hanna
- UCL Queen Square Motor Neuron Disease Centre, UCL Queen Square Institute of Neurology, University College London, Queen Square, London, WC1N 3BG UK
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, University College London, Queen Square, London, WC1N 3BG UK
| | - Giampietro Schiavo
- UCL Queen Square Motor Neuron Disease Centre, UCL Queen Square Institute of Neurology, University College London, Queen Square, London, WC1N 3BG UK
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, University College London, Queen Square, London, WC1N 3BG UK
- UK Dementia Research Institute at UCL, London, WC1E 6BT UK
| | - Adrian M. Isaacs
- UCL Queen Square Motor Neuron Disease Centre, UCL Queen Square Institute of Neurology, University College London, Queen Square, London, WC1N 3BG UK
- UK Dementia Research Institute at UCL, London, WC1E 6BT UK
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, Queen Square, London, WC1N 3BG UK
| | - Richard W. Orrell
- UCL Queen Square Motor Neuron Disease Centre, UCL Queen Square Institute of Neurology, University College London, Queen Square, London, WC1N 3BG UK
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, University College London, Queen Square, London, WC1N 3BG UK
| | - Thomas J. Cunningham
- MRC Prion Unit at UCL, Courtauld Building, 33 Cleveland Street, London, W1W 7FF UK
| | - Abraham Acevedo Arozena
- Research Unit, Hospital Universitario de Canarias, ITB-ULL and CIBERNED, La Laguna, 38320 Spain
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Olfati N, Ghodsi H, Bayram E, Litvan I. Why Therapeutic Trials Fail in Primary Tauopathies. Mov Disord 2023; 38:545-550. [PMID: 36670054 PMCID: PMC10398638 DOI: 10.1002/mds.29322] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/08/2022] [Accepted: 12/28/2022] [Indexed: 01/22/2023] Open
Affiliation(s)
- Nahid Olfati
- Parkinson and Other Movement Disorders Center, Department of Neurosciences, University of California San Diego, La Jolla, CA, USA
| | - Hamidreza Ghodsi
- Parkinson and Other Movement Disorders Center, Department of Neurosciences, University of California San Diego, La Jolla, CA, USA
| | - Ece Bayram
- Parkinson and Other Movement Disorders Center, Department of Neurosciences, University of California San Diego, La Jolla, CA, USA
| | - Irene Litvan
- Parkinson and Other Movement Disorders Center, Department of Neurosciences, University of California San Diego, La Jolla, CA, USA
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Mead RJ, Shan N, Reiser HJ, Marshall F, Shaw PJ. Amyotrophic lateral sclerosis: a neurodegenerative disorder poised for successful therapeutic translation. Nat Rev Drug Discov 2023; 22:185-212. [PMID: 36543887 PMCID: PMC9768794 DOI: 10.1038/s41573-022-00612-2] [Citation(s) in RCA: 99] [Impact Index Per Article: 99.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2022] [Indexed: 12/24/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a devastating disease caused by degeneration of motor neurons. As with all major neurodegenerative disorders, development of disease-modifying therapies has proven challenging for multiple reasons. Nevertheless, ALS is one of the few neurodegenerative diseases for which disease-modifying therapies are approved. Significant discoveries and advances have been made in ALS preclinical models, genetics, pathology, biomarkers, imaging and clinical readouts over the last 10-15 years. At the same time, novel therapeutic paradigms are being applied in areas of high unmet medical need, including neurodegenerative disorders. These developments have evolved our knowledge base, allowing identification of targeted candidate therapies for ALS with diverse mechanisms of action. In this Review, we discuss how this advanced knowledge, aligned with new approaches, can enable effective translation of therapeutic agents from preclinical studies through to clinical benefit for patients with ALS. We anticipate that this approach in ALS will also positively impact the field of drug discovery for neurodegenerative disorders more broadly.
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Affiliation(s)
- Richard J Mead
- Sheffield Institute for Translational Neuroscience, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK
- Neuroscience Institute, University of Sheffield, Sheffield, UK
- Keapstone Therapeutics, The Innovation Centre, Broomhall, Sheffield, UK
| | - Ning Shan
- Aclipse Therapeutics, Radnor, PA, US
| | | | - Fiona Marshall
- MSD UK Discovery Centre, Merck, Sharp and Dohme (UK) Limited, London, UK
| | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK.
- Neuroscience Institute, University of Sheffield, Sheffield, UK.
- Keapstone Therapeutics, The Innovation Centre, Broomhall, Sheffield, UK.
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Walter MC, Laforêt P, van der Pol WL, Pegoraro E. 254th ENMC International Virtual Workshop Formation of a European network to initiate a European data collection, along with development and sharing of treatment guidelines for adult SMA patients 28 – 30 January 2022. Neuromuscul Disord 2023; 33:511-522. [PMID: 37245491 DOI: 10.1016/j.nmd.2023.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/14/2023] [Accepted: 03/26/2023] [Indexed: 03/31/2023]
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Lekstrom-Himes J, Brooks PJ, Koeberl DD, Brower A, Goldenberg A, Green RC, Morris JA, Orsini JJ, Yu TW, Augustine EF. Moving away from one disease at a time: Screening, trial design, and regulatory implications of novel platform technologies. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2023; 193:30-43. [PMID: 36738469 PMCID: PMC10038900 DOI: 10.1002/ajmg.c.32031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/16/2022] [Accepted: 01/04/2023] [Indexed: 02/06/2023]
Abstract
Most rare diseases are caused by single-gene mutations, and as such, lend themselves to a host of new gene-targeted therapies and technologies including antisense oligonucleotides, phosphomorpholinos, small interfering RNAs, and a variety of gene delivery and gene editing systems. Early successes are encouraging, however, given the substantial number of distinct rare diseases, the ability to scale these successes will be unsustainable without new development efficiencies. Herein, we discuss the need for genomic newborn screening to match pace with the growing development of targeted therapeutics and ability to rapidly develop individualized therapies for rare variants. We offer approaches to move beyond conventional "one disease at a time" preclinical and clinical drug development and discuss planned regulatory innovations that are necessary to speed therapy delivery to individuals in need. These proposals leverage the shared properties of platform classes of therapeutics and innovative trial designs including master and platform protocols to better serve patients and accelerate drug development. Ultimately, there are risks to these novel approaches; however, we believe that close partnership and transparency between health authorities, patients, researchers, and drug developers present the path forward to overcome these challenges and deliver on the promise of gene-targeted therapies for rare diseases.
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Affiliation(s)
| | - P J Brooks
- Division of Rare Diseases Research Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, Maryland, USA
| | - Dwight D Koeberl
- Division of Medical Genetics, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amy Brower
- American College of Medical Genetics and Genomics, Bethesda, Maryland, USA
| | - Aaron Goldenberg
- Department of Bioethics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Robert C Green
- Mass General Brigham, Broad Institute, Ariadne Labs and Harvard Medical School, Boston, MA, USA
| | - Jill A Morris
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Joseph J Orsini
- Wadsworth Center, New York State Department of Health, Albany, New York, USA
| | - Timothy W Yu
- Division of Genetics and Genomics, Harvard Medical School, Boston, Massachusetts, USA
| | - Erika F Augustine
- Department of Neurology and Neurodevelopmental Medicine, Kennedy Krieger Institute, Baltimore, Maryland, USA
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Schor NF, Cudkowicz ME, Banwell B. Academic Neurology and the COVID-19 Pandemic: Resilience, Hope, and Solutions. Neurology 2023; 100:430-436. [PMID: 36456201 PMCID: PMC9990443 DOI: 10.1212/wnl.0000000000201571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 09/28/2022] [Indexed: 12/03/2022] Open
Abstract
The SARS-CoV-2 (COVID-19) viral pandemic dramatically affected human health, health care delivery, health care workers, and health care research worldwide. The field of academic neurology was no exception. In this 2022 Presidential Plenary, we discuss the challenges faced by neurologists and neuroscientists professionally and personally. We review the threats posed by the pandemic to neuroscience research activities, materials, productivity, and funding. We then discuss the impact of the pandemic on clinical trials for neurologic diseases. Restrictions to patient enrolment due to limited in-person access to laboratory testing, imaging, and study visits led to delay in both clinical trial enrolment and study completion but also to innovative new means to engage clinical trial participants remotely and to strategies to critically appraise the frequency and design of trial-related patient evaluations. Clinical care was also challenged by initial pandemic prioritization of urgent visit and inpatient care and the rapid pivot to telehealth for most other neurology care encounters. Front-line neurology care teams faced their fears of infection, with the first few months of the pandemic being characterized by uncertainty, inconsistent national health care strategies, limited personal protective equipment, and an alarming rate of human illness and death caused by COVID-19. The personal and societal toll of the pandemic is incalculable. Across research and clinical neurology providers, women and particularly those with young families juggled the impossible balance of career and family care as schools closed and children required home-based education. Shining through this dark time are lessons that should shape a brighter future for our field. We are resilient, and the advances in neuroscience and neurology care continue to advance improved neurologic outcomes. The National Institutes of Health devised multiple support strategies for researchers to help bridge the pandemic. Telehealth, clinical trial designs that are more participant-centric with remote monitoring, and flexible work schedules are strategies to rebalance overworked lives and improve our engagement with our patients. As we re-emerge, we have the chance to reframe our field.
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Affiliation(s)
- Nina F Schor
- From the National Institutes of Health (N.F.S.), Bethesda, MD; Massachusetts General Hospital (M.E.C.), Harvard Medical School, Boston, MA; Children's Hospital of Philadelphia (B.B), Perelman School of Medicine, University of Pennsylvania, PA
| | - Merit E Cudkowicz
- From the National Institutes of Health (N.F.S.), Bethesda, MD; Massachusetts General Hospital (M.E.C.), Harvard Medical School, Boston, MA; Children's Hospital of Philadelphia (B.B), Perelman School of Medicine, University of Pennsylvania, PA
| | - Brenda Banwell
- From the National Institutes of Health (N.F.S.), Bethesda, MD; Massachusetts General Hospital (M.E.C.), Harvard Medical School, Boston, MA; Children's Hospital of Philadelphia (B.B), Perelman School of Medicine, University of Pennsylvania, PA.
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Adaptive clinical trials and master protocols. HANDBOOK OF CLINICAL NEUROLOGY 2023; 193:313-323. [PMID: 36803819 DOI: 10.1016/b978-0-323-85555-6.00005-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Methodologies for randomized, double-blind, placebo-controlled clinical trials continue to develop in concert with evolving scientific and translational knowledge. Adaptive trial designs, in which data generated during the study are used to modify subsequent study activity (i.e., sample sizes, entry criteria, or outcomes), can optimize flexibility and expedite the safety and efficacy assessments for interventions of interest. This chapter will summarize general designs, advantages, and pitfalls associated with adaptive clinical trials and compare their features with those of conventional trial designs. It will also review novel ways for which seamless designs and master protocols may improve trial efficiency while offering interpretable data.
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Martinez-Gonzalez L, Martinez A. Emerging clinical investigational drugs for the treatment of amyotrophic lateral sclerosis. Expert Opin Investig Drugs 2023; 32:141-160. [PMID: 36762798 DOI: 10.1080/13543784.2023.2178416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder caused by motoneuron death with a median survival time of 3-5 years since disease onset. There are no effective treatments to date. However, a variety of innovative investigational drugs and biological-based therapies are under clinical development. AREAS COVERED This review provides an overview of the clinical investigational small molecules as well as a brief summary of the biological-based therapies that are currently undergoing clinical trials for the treatment of ALS. All the data were obtained from ClinicalTrials.gov (registered through November 1). EXPERT OPINION Drug discovery for ALS is an active and evolving field, where many investigational clinical drugs are in different trials. There are several mechanisms of action supporting all these new therapies, although proteostasis is gaining stage. Probably, small orally bioavailable molecules able to recover functional TDP-43 homeostasis may have solid chances to modify ALS progression.
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Affiliation(s)
- Loreto Martinez-Gonzalez
- Centro de Investigaciones Biológicas "Margarita Salas"-CSIC, Madrid, Spain.,Centro de Investigación Biomédica en Red en enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
| | - Ana Martinez
- Centro de Investigaciones Biológicas "Margarita Salas"-CSIC, Madrid, Spain.,Centro de Investigación Biomédica en Red en enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
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Abstract
The scientific landscape surrounding amyotrophic lateral sclerosis has shifted immensely with a number of well-defined ALS disease-causing genes, each with related phenotypical and cellular motor neuron processes that have come to light. Yet in spite of decades of research and clinical investigation, there is still no etiology for sporadic amyotrophic lateral sclerosis, and treatment options even for those with well-defined familial syndromes are still limited. This chapter provides a comprehensive review of the genetic basis of amyotrophic lateral sclerosis, highlighting factors that contribute to its heritability and phenotypic manifestations, and an overview of past, present, and upcoming therapeutic strategies.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
| | - Robert H Brown
- Department of Neurology, UMass Chan Medical School, Donna M. and Robert J. Manning Chair in Neurosciences and Director in Neurotherapeutics, Worcester, MA, United States
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Broglio K, Niewczas J, Wathen K. Who wants to go first? A simulation study of accrual in a stand-alone trial versus starting a platform trial. Contemp Clin Trials 2022; 123:107000. [PMID: 36372160 DOI: 10.1016/j.cct.2022.107000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/31/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022]
Abstract
Others have quantified the efficiency of the platform approach as compared to a sequence of independent two-arm trials and have shown the platform approach more efficiently evaluates a set of candidate therapies. However, a practical barrier to initiating a platform trial is incentivizing the first candidate therapies to enter the platform. A platform trial is more complex and will take longer to design and operationalize than a traditional trial. For the first therapy, this additional up-front planning time must be considered along with the ability to enroll. There is a common concern that accrual in a platform setting would take longer than for a single stand-alone trial because intuition suggests that a two-arm trial with a smaller total sample size should complete accrual more quickly than a multi-armed trial. We focus on the accrual duration for the first therapy as a particular barrier to initiating a platform trial strategy. We simulate accrual into a platform trial versus a stand-alone trial in the setting of a large clinical trial network. Accrual duration in the platform strategy dominates that of a single stand-alone trial if the platform leverages a large enough fraction of the site network. Patient preference for a particular stand-alone trial has little impact on the ability of a stand-alone trial to enroll more quickly.
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Affiliation(s)
- Kristine Broglio
- AstraZeneca, Oncology Statistical Innovation, Gaithersburg, MD, USA.
| | - Julia Niewczas
- Janssen, Statistical Modeling and Methodology, Gothenburg, Sweden.
| | - Kyle Wathen
- Cytel, Scientific Strategy and Innovation, Waltham, MA, USA.
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Bronson A, Chase MK, Fisher K, Millar D, Perlmutter J, Richardson N. Mobilizing the clinical trial ecosystem to drive adoption of master protocols. Clin Trials 2022; 19:690-696. [PMID: 36086812 PMCID: PMC9679560 DOI: 10.1177/17407745221110199] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Master protocol studies typically use an overarching protocol to answer several questions by guiding a variety of sub-studies. These sub-studies can incorporate multiple diseases, therapies, or both. Although this innovative approach offers many benefits, including the ability to deliver clinical research that is more patient-centric and efficient, several common barriers curtail widespread adoption. The Clinical Trials Transformation Initiative (CTTI) convened industry representatives, regulatory agencies, patient groups, and academic institutions to identify emerging best practices and develop resources designed to help sponsors and other stakeholders overcome these challenges. We first identify some broad changes needed in the clinical trials ecosystem to facilitate mainstream adoption of master protocol studies, and we subsequently summarize CTTI's resources designed to support this effort.
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Affiliation(s)
- Abby Bronson
- Parent Project Muscular Dystrophy,
Washington, DC, USA,Edgewise Therapeutics, Boulder, CO,
USA
| | - Marianne K Chase
- Sean M. Healey & AMG Center,
Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | | | | | | | - Nicholas Richardson
- Office of Oncologic Diseases, Center
for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring,
MD, USA,Nicholas Richardson, US Food and Drug
Administration, 10903 New Hampshire Ave, White Oak Building 22, Silver Spring,
MD 20993, USA.
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34
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Staffaroni AM, Quintana M, Wendelberger B, Heuer HW, Russell LL, Cobigo Y, Wolf A, Goh SYM, Petrucelli L, Gendron TF, Heller C, Clark AL, Taylor JC, Wise A, Ong E, Forsberg L, Brushaber D, Rojas JC, VandeVrede L, Ljubenkov P, Kramer J, Casaletto KB, Appleby B, Bordelon Y, Botha H, Dickerson BC, Domoto-Reilly K, Fields JA, Foroud T, Gavrilova R, Geschwind D, Ghoshal N, Goldman J, Graff-Radford J, Graff-Radford N, Grossman M, Hall MGH, Hsiung GY, Huey ED, Irwin D, Jones DT, Kantarci K, Kaufer D, Knopman D, Kremers W, Lago AL, Lapid MI, Litvan I, Lucente D, Mackenzie IR, Mendez MF, Mester C, Miller BL, Onyike CU, Rademakers R, Ramanan VK, Ramos EM, Rao M, Rascovsky K, Rankin KP, Roberson ED, Savica R, Tartaglia MC, Weintraub S, Wong B, Cash DM, Bouzigues A, Swift IJ, Peakman G, Bocchetta M, Todd EG, Convery RS, Rowe JB, Borroni B, Galimberti D, Tiraboschi P, Masellis M, Finger E, van Swieten JC, Seelaar H, Jiskoot LC, Sorbi S, Butler CR, Graff C, Gerhard A, Langheinrich T, Laforce R, Sanchez-Valle R, de Mendonça A, Moreno F, Synofzik M, Vandenberghe R, Ducharme S, Le Ber I, Levin J, Danek A, Otto M, Pasquier F, Santana I, Kornak J, Boeve BF, Rosen HJ, Rohrer JD, Boxer AL. Temporal order of clinical and biomarker changes in familial frontotemporal dementia. Nat Med 2022; 28:2194-2206. [PMID: 36138153 PMCID: PMC9951811 DOI: 10.1038/s41591-022-01942-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 07/08/2022] [Indexed: 01/17/2023]
Abstract
Unlike familial Alzheimer's disease, we have been unable to accurately predict symptom onset in presymptomatic familial frontotemporal dementia (f-FTD) mutation carriers, which is a major hurdle to designing disease prevention trials. We developed multimodal models for f-FTD disease progression and estimated clinical trial sample sizes in C9orf72, GRN and MAPT mutation carriers. Models included longitudinal clinical and neuropsychological scores, regional brain volumes and plasma neurofilament light chain (NfL) in 796 carriers and 412 noncarrier controls. We found that the temporal ordering of clinical and biomarker progression differed by genotype. In prevention-trial simulations using model-based patient selection, atrophy and NfL were the best endpoints, whereas clinical measures were potential endpoints in early symptomatic trials. f-FTD prevention trials are feasible but will likely require global recruitment efforts. These disease progression models will facilitate the planning of f-FTD clinical trials, including the selection of optimal endpoints and enrollment criteria to maximize power to detect treatment effects.
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Affiliation(s)
- Adam M Staffaroni
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA.
| | | | | | - Hilary W Heuer
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Lucy L Russell
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square London, London, UK
| | - Yann Cobigo
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Amy Wolf
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Sheng-Yang Matt Goh
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | | | - Tania F Gendron
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA
| | - Carolin Heller
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square London, London, UK
| | - Annie L Clark
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Jack Carson Taylor
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Amy Wise
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Elise Ong
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Leah Forsberg
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Danielle Brushaber
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Julio C Rojas
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Lawren VandeVrede
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Peter Ljubenkov
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Joel Kramer
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Kaitlin B Casaletto
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Brian Appleby
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
| | - Yvette Bordelon
- Department of Neurology, University of California, Los Angeles, Los Angeles, USA
| | - Hugo Botha
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Bradford C Dickerson
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Julie A Fields
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Tatiana Foroud
- Indiana University School of Medicine, National Centralized Repository for Alzheimer's, Indianapolis, IN, USA
| | | | - Daniel Geschwind
- Department of Neurology, University of California, Los Angeles, Los Angeles, USA
- Institute for Precision Health, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Nupur Ghoshal
- Departments of Neurology and Psychiatry, Washington University School of Medicine, Washington University, St. Louis, MO, USA
| | - Jill Goldman
- Department of Neurology, Columbia University, New York, NY, USA
| | | | | | - Murray Grossman
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew G H Hall
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Ging-Yuek Hsiung
- Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Edward D Huey
- Department of Neurology, Columbia University, New York, NY, USA
| | - David Irwin
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - David T Jones
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Kejal Kantarci
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Daniel Kaufer
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - David Knopman
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Walter Kremers
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Argentina Lario Lago
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Maria I Lapid
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Irene Litvan
- Department of Neurosciences, University of California, San Diego, La Jolla, CA, USA
| | - Diane Lucente
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ian R Mackenzie
- Department of Pathology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mario F Mendez
- Department of Neurology, University of California, Los Angeles, Los Angeles, USA
| | - Carly Mester
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Bruce L Miller
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Chiadi U Onyike
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Rosa Rademakers
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA
- Applied and Translational Neurogenomics Group, VIB Center for Molecular Neurology, VIB, Antwerp, Belgium
- Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | | | - Eliana Marisa Ramos
- Department of Neurology, University of California, Los Angeles, Los Angeles, USA
| | - Meghana Rao
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Katya Rascovsky
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Katherine P Rankin
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Erik D Roberson
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rodolfo Savica
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - M Carmela Tartaglia
- Tanz Centre for Research in Neurodegenerative Diseases, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Sandra Weintraub
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Bonnie Wong
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - David M Cash
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square London, London, UK
| | - Arabella Bouzigues
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square London, London, UK
| | - Imogen J Swift
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square London, London, UK
| | - Georgia Peakman
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square London, London, UK
| | - Martina Bocchetta
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square London, London, UK
| | - Emily G Todd
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square London, London, UK
| | - Rhian S Convery
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square London, London, UK
| | - James B Rowe
- Department of Clinical Neurosciences and Cambridge University Hospitals NHS Trust and Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Barbara Borroni
- Centre for Neurodegenerative Disorders, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Daniela Galimberti
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Mario Masellis
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre; Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Finger
- Department of Clinical Neurological Sciences, University of Western Ontario, London, Ontario, Canada
| | | | - Harro Seelaar
- Department of Neurology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Lize C Jiskoot
- Department of Neurology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Sandro Sorbi
- Department of Neurofarba, University of Florence, Florence, Italy
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Chris R Butler
- Nuffield Department of Clinical Neurosciences, Medical Sciences Division, University of Oxford, Oxford, UK
- Department of Brain Sciences, Imperial College London, London, UK
| | - Caroline Graff
- Center for Alzheimer Research, Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Bioclinicum, Karolinska Institutet, Solna, Sweden
- Unit for Hereditary Dementias, Theme Aging, Karolinska University Hospital, Solna, Sweden
| | - Alexander Gerhard
- Division of Neuroscience and Experimental Psychology, Wolfson Molecular Imaging Centre, University of Manchester, Manchester, UK
- Departments of Geriatric Medicine and Nuclear Medicine, Center for Translational Neuro- and Behavioral Sciences, University Medicine Essen, Essen, Germany
| | - Tobias Langheinrich
- Division of Neuroscience and Experimental Psychology, Wolfson Molecular Imaging Centre, University of Manchester, Manchester, UK
- Cerebral Function Unit, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
| | - Robert Laforce
- Clinique Interdisciplinaire de Mémoire, Département des Sciences Neurologiques, CHU de Québec, and Faculté de Médecine, Université Laval, Québec City, Québec, Canada
| | - Raquel Sanchez-Valle
- Alzheimer's disease and Other Cognitive Disorders Unit, Neurology Service, Hospital Clínic, Institut d'Investigacións Biomèdiques August Pi I Sunyer, University of Barcelona, Barcelona, Spain
| | | | - Fermin Moreno
- Cognitive Disorders Unit, Department of Neurology, Donostia University Hospital, San Sebastian, Gipuzkoa, Spain
- Neuroscience Area, Biodonostia Health Research Institute, San Sebastian, Gipuzkoa, Spain
| | - Matthis Synofzik
- Department of Neurodegenerative Diseases, Hertie-Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Tübingen, Germany
- Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
| | - Rik Vandenberghe
- Laboratory for Cognitive Neurology, Department of Neurosciences, KU Leuven, Leuven, Belgium
- Neurology Service, University Hospitals Leuven, Leuven, Belgium
- Leuven Brain Institute, KU Leuven, Leuven, Belgium
| | - Simon Ducharme
- Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montreal, Canada
- McConnell Brain Imaging Centre, Montreal Neurological Institute, Department of Neurology & Neurosurgery, McGill University, Montreal, Québec, Canada
| | - Isabelle Le Ber
- Sorbonne Université, Paris Brain Institute - Institut du Cerveau - ICM, Inserm U1127, CNRS UMR 7225, AP-HP - Hôpital Pitié-Salpêtrière, Paris, France
- Centre de référence des démences rares ou précoces, IM2A, Département de Neurologie, AP-HP - Hôpital Pitié-Salpêtrière, Paris, France
- Département de Neurologie, AP-HP - Hôpital Pitié-Salpêtrière, Paris, France
| | - Johannes Levin
- Neurologische Klinik und Poliklinik, Ludwig-Maximilians-Universität, Munich, Germany
- Center for Neurodegenerative Diseases (DZNE), Munich, Germany
- Munich Cluster of Systems Neurology, Munich, Germany
| | - Adrian Danek
- Neurologische Klinik und Poliklinik, Ludwig-Maximilians-Universität, Munich, Germany
| | - Markus Otto
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Florence Pasquier
- University of Lille, Lille, France
- Inserm, Lille, France
- CHU, CNR-MAJ, Labex Distalz, LiCEND Lille, Lille, France
| | - Isabel Santana
- Neurology Service, Faculty of Medicine, University Hospital of Coimbra (HUC), University of Coimbra, Coimbra, Portugal
- Center for Neuroscience and Cell Biology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - John Kornak
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | | | - Howard J Rosen
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Jonathan D Rohrer
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square London, London, UK
| | - Adam L Boxer
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA.
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Johnson SA, Fang T, De Marchi F, Neel D, Van Weehaeghe D, Berry JD, Paganoni S. Pharmacotherapy for Amyotrophic Lateral Sclerosis: A Review of Approved and Upcoming Agents. Drugs 2022; 82:1367-1388. [PMID: 36121612 DOI: 10.1007/s40265-022-01769-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2022] [Indexed: 11/03/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a rapidly progressive neurodegenerative disorder involving loss of upper and lower motor neurons, with most cases ending in death within 3-5 years of onset. Several molecular and cellular pathways have been identified to cause ALS; however, treatments to stop or reverse disease progression are yet to be found. Riluzole, a neuroprotective agent offering only a modest survival benefit, has long been the sole disease-modifying therapy for ALS. Edaravone, which demonstrated statistically significant slowing of ALS disease progression, is gaining approval in an increasing number of countries since its first approval in 2015. Sodium phenylbutyrate and taurursodiol (PB-TURSO) was conditionally approved in Canada in 2022, having shown significant slowing of disease progression and prolonged survival. Most clinical trials have focused on testing small molecules affecting common cellular pathways in ALS: targeting glutamatergic, apoptotic, inflammatory, and oxidative stress mechanisms among others. More recently, clinical trials utilizing stem cell transplantation and other biologics have emerged. This rich and ever-growing pipeline of investigational products, along with innovative clinical trial designs, collaborative trial networks, and an engaged ALS community', provide renewed hope to finding a cure for ALS. This article reviews existing ALS therapies and the current clinical drug development pipeline.
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Affiliation(s)
- Stephen A Johnson
- Neurological Clinical Research Institute (NCRI), Healey & AMG Center for ALS, Massachusetts General Hospital, 165 Cambridge St, Suite 600, Boston, MA, 02114, USA
| | - Ton Fang
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Fabiola De Marchi
- Department of Neurology, ALS Centre, Maggiore della Carità Hospital, Novara, Italy
- Department of Translational Medicine, University of Piemonte Orientale, 28100, Novara, Italy
| | | | - Donatienne Van Weehaeghe
- Nuclear Medicine Subdivision, Department of Imaging and Pathology, University Hospital Leuven, Leuven, Belgium
| | - James D Berry
- Neurological Clinical Research Institute (NCRI), Healey & AMG Center for ALS, Massachusetts General Hospital, 165 Cambridge St, Suite 600, Boston, MA, 02114, USA
| | - Sabrina Paganoni
- Neurological Clinical Research Institute (NCRI), Healey & AMG Center for ALS, Massachusetts General Hospital, 165 Cambridge St, Suite 600, Boston, MA, 02114, USA.
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, USA.
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36
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MacPherson A, Gumnit E, Ouimet C, Hutchinson N, Kieburtz K, Pearson TS, Kimmelman J. Quantifying Patient Investment in Novel Neurological Drug Development. Neurotherapeutics 2022; 19:1507-1513. [PMID: 35764764 PMCID: PMC9606150 DOI: 10.1007/s13311-022-01259-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 10/17/2022] Open
Abstract
While the drug development literature provides numerous estimates of the financial costs to bring a new drug to market, the investment of patient-participants in the research process has not been described. Trial participants and their caregivers, like companies, invest time and undertake risk when they participate in prelicense trials. We determined the average number of patient-participants needed to develop a novel neurological drug. We created a cohort of 108 unapproved drugs first tested for efficacy between 2006 and 2011 and used ClinicalTrials.gov to capture enrollment in all subsequent prelicense trials of these drugs over a 9-year period. Our primary outcome was the average number of patients enrolled in prelicense neurological drug trials per drug that ultimately attained FDA approval, including patients who participated in both successful and unsuccessful development efforts. Five drugs (4.6%) were FDA approved, and 66,751 patient-participants were enrolled across successful and unsuccessful drug development efforts, resulting in an average of 13,350 patients for each drug attaining approval (95% CI 7155 to 54,954). Our estimates reveal the substantial amount patients and their caregivers contribute to private drug development.
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Affiliation(s)
- Amanda MacPherson
- Department of Equity, Ethics and Policy, McGill University School of Population and Global Health, 2001 McGill College Avenue, Montreal, QC, H3A 1G1 Canada
| | - Elias Gumnit
- Department of Equity, Ethics and Policy, McGill University School of Population and Global Health, 2001 McGill College Avenue, Montreal, QC, H3A 1G1 Canada
| | - Charlotte Ouimet
- Department of Equity, Ethics and Policy, McGill University School of Population and Global Health, 2001 McGill College Avenue, Montreal, QC, H3A 1G1 Canada
| | - Nora Hutchinson
- Department of Equity, Ethics and Policy, McGill University School of Population and Global Health, 2001 McGill College Avenue, Montreal, QC, H3A 1G1 Canada
| | - Karl Kieburtz
- Department of Neurology, University of Rochester, Rochester, NY USA
| | - Toni S. Pearson
- Department of Neurology, Washington University School of Medicine, St. Louis, MO USA
| | - Jonathan Kimmelman
- Department of Equity, Ethics and Policy, McGill University School of Population and Global Health, 2001 McGill College Avenue, Montreal, QC, H3A 1G1 Canada
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Dentoni G, Castro-Aldrete L, Naia L, Ankarcrona M. The Potential of Small Molecules to Modulate the Mitochondria–Endoplasmic Reticulum Interplay in Alzheimer’s Disease. Front Cell Dev Biol 2022; 10:920228. [PMID: 36092728 PMCID: PMC9459385 DOI: 10.3389/fcell.2022.920228] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/08/2022] [Indexed: 11/13/2022] Open
Abstract
Alzheimer’s disease (AD) is the most common neurodegenerative disease affecting a growing number of elderly individuals. No disease-modifying drugs have yet been identified despite over 30 years of research on the topic, showing the need for further research on this multifactorial disease. In addition to the accumulation of amyloid β-peptide (Aβ) and hyperphosphorylated tau (p-tau), several other alterations have been associated with AD such as calcium (Ca2+) signaling, glucose-, fatty acid-, cholesterol-, and phospholipid metabolism, inflammation, and mitochondrial dysfunction. Interestingly, all these processes have been associated with the mitochondria–endoplasmic reticulum (ER) contact site (MERCS) signaling hub. We and others have hypothesized that the dysregulated MERCS function may be one of the main pathogenic pathways driving AD pathology. Due to the variety of biological processes overseen at the MERCS, we believe that they constitute unique therapeutic targets to boost the neuronal function and recover neuronal homeostasis. Thus, developing molecules with the capacity to correct and/or modulate the MERCS interplay can unleash unique therapeutic opportunities for AD. The potential pharmacological intervention using MERCS modulators in different models of AD is currently under investigation. Here, we survey small molecules with the potential to modulate MERCS structures and functions and restore neuronal homeostasis in AD. We will focus on recently reported examples and provide an overview of the current challenges and future perspectives to develop MERCS modulators in the context of translational research.
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Wong C, Dakin RS, Williamson J, Newton J, Steven M, Colville S, Stavrou M, Gregory JM, Elliott E, Mehta AR, Chataway J, Swingler RJ, Parker RA, Weir CJ, Stallard N, Parmar MKB, Macleod MR, Pal S, Chandran S. Motor Neuron Disease Systematic Multi-Arm Adaptive Randomised Trial (MND-SMART): a multi-arm, multi-stage, adaptive, platform, phase III randomised, double-blind, placebo-controlled trial of repurposed drugs in motor neuron disease. BMJ Open 2022; 12:e064173. [PMID: 35798516 PMCID: PMC9263927 DOI: 10.1136/bmjopen-2022-064173] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Motor neuron disease (MND) is a rapidly fatal neurodegenerative disease. Despite decades of research and clinical trials there remains no cure and only one globally approved drug, riluzole, which prolongs survival by 2-3 months. Recent improved mechanistic understanding of MND heralds a new translational era with many potential targets being identified that are ripe for clinical trials. Motor Neuron Disease Systematic Multi-Arm Adaptive Randomised Trial (MND-SMART) aims to evaluate the efficacy of drugs efficiently and definitively in a multi-arm, multi-stage, adaptive trial. The first two drugs selected for evaluation in MND-SMART are trazodone and memantine. METHODS AND ANALYSIS Initially, up to 531 participants (177/arm) will be randomised 1:1:1 to oral liquid trazodone, memantine and placebo. The coprimary outcome measures are the Amyotrophic Lateral Sclerosis Functional Rating Scale Revised (ALSFRS-R) and survival. Comparisons will be conducted in four stages. The decision to continue randomising to arms after each stage will be made by the Trial Steering Committee who receive recommendations from the Independent Data Monitoring Committee. The primary analysis of ALSFRS-R will be conducted when 150 participants/arm, excluding long survivors, have completed 18 months of treatment; if positive the survival effect will be inferentially analysed when 113 deaths have been observed in the placebo group. The trial design ensures that other promising drugs can be added for evaluation in planned trial adaptations. Using this novel trial design reduces time, cost and number of participants required to definitively (phase III) evaluate drugs and reduces exposure of participants to potentially ineffective treatments. ETHICS AND DISSEMINATION MND-SMART was approved by the West of Scotland Research Ethics Committee on 2 October 2019. (REC reference: 19/WS/0123) Results of the study will be submitted for publication in a peer-reviewed journal and a summary provided to participants. TRIAL REGISTRATION NUMBERS European Clinical Trials Registry (2019-000099-41); NCT04302870.
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Affiliation(s)
- Charis Wong
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Rachel S Dakin
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Jill Williamson
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Judith Newton
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Michelle Steven
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Shuna Colville
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Maria Stavrou
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Jenna M Gregory
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Elizabeth Elliott
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Arpan R Mehta
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK
- Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Robert J Swingler
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- London North West University Healthcare NHS Trust, Northwick Park Hospital, London, UK
| | - Richard Anthony Parker
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Nigel Stallard
- Statistics and Epidemiology, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Mahesh K B Parmar
- Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Malcolm R Macleod
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Suvankar Pal
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Siddharthan Chandran
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute Edinburgh, University of Edinburgh, Edinburgh, UK
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Fournier CN. Considerations for Amyotrophic Lateral Sclerosis (ALS) Clinical Trial Design. Neurotherapeutics 2022; 19:1180-1192. [PMID: 35819713 PMCID: PMC9275386 DOI: 10.1007/s13311-022-01271-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 11/20/2022] Open
Abstract
Thoughtful clinical trial design is critical for efficient therapeutic development, particularly in the field of amyotrophic lateral sclerosis (ALS), where trials often aim to detect modest treatment effects among a population with heterogeneous disease progression. Appropriate outcome measure selection is necessary for trials to provide decisive and informative results. Investigators must consider the outcome measure's reliability, responsiveness to detect change when change has actually occurred, clinical relevance, and psychometric performance. ALS clinical trials can also be performed more efficiently by utilizing statistical enrichment techniques. Innovations in ALS prediction models allow for selection of participants with less heterogeneity in disease progression rates without requiring a lead-in period, or participants can be stratified according to predicted progression. Statistical enrichment can reduce the needed sample size and improve study power, but investigators must find a balance between optimizing statistical efficiency and retaining generalizability of study findings to the broader ALS population. Additional progress is still needed for biomarker development and validation to confirm target engagement in ALS treatment trials. Selection of an appropriate biofluid biomarker depends on the treatment mechanism of interest, and biomarker studies should be incorporated into early phase trials. Inclusion of patients with ALS as advisors and advocates can strengthen clinical trial design and study retention, but more engagement efforts are needed to improve diversity and equity in ALS research studies. Another challenge for ALS therapeutic development is identifying ways to respect patient autonomy and improve access to experimental treatment, something that is strongly desired by many patients with ALS and ALS advocacy organizations. Expanded access programs that run concurrently to well-designed and adequately powered randomized controlled trials may provide an opportunity to broaden access to promising therapeutics without compromising scientific integrity or rushing regulatory approval of therapies without adequate proof of efficacy.
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Affiliation(s)
- Christina N Fournier
- Department of Neurology, Emory University, Atlanta, GA, USA.
- Department of Veterans Affairs, Atlanta, GA, USA.
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